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The changing spectrum of disease, etiology, and diagnosis of mucormycosis
MUCORMYCOSIS--MARCtlEvsKv 54. Fawcett, D. W.: An Atlas of Fine Structure. The Cell, Its Organelles and Inclusions. i'hiladelphia, W. B. Saunders Company, 1966, p. 189. 55. Hirata, Y., et al.: Gastric carcinoid with ectopic production of AGTII and B-MS|I. Cancer, 37:377, 1976. 56. Black, W. C.: Enterochromaffin cell types and corresponding carcinoid tumors. L'~b. Invest., 19:.t73, 1968.
E T AL.
57. Qizilbash, A., et al.: Functioning primary carcinoid tumor of the ovary. Am. J. Clin. Path., 62:629, 197.t. 58. Stoebner, P., et al.: Ultrastructure of anaplastic bronchial carcinomas. Cancer, 20:286, 1967. Department of Pathology and Area Laboratory Services Brooke Arm)" Medical Center Fort Sam ltot,ston, Texas 78234 (Dr. Herrera)
THE C H A N G I N G SPECTRUM OF DISEASE, ETIOLOGY, A N D D I A G N O S I S OF MUCORMYCOSIS Alberto M. Marchevsky, M.D.,* Edward J. Bottone, Ph.D.,t Stephen A. Gelled, M.D.,$ and Donald K. Gige~, Ph.D.w Abstract During tim 20 year interval f r o m 1958 t h r o u g h 1978 a c h a n g e in the spectrum o f disease, etiology, a n d diagnosis o f mucormycosis was observed at T h e M o u n t Sinai Hospital. Alflmugh the rltinocerebral and p u l m o n a r y forms o f mucormycosis were still the most f r e q u e n t forms o f disease, hospital acqtfired c u t a n e o u s and subcntaneous infections emerged. Since 1974, 14 o f 15 cases o f mucormycosis were diagnosed d u r i n g life. Rhizopus species, especially R. rhizopodoformis, have been the etiologic agents identified in 13 o f 14 cuhurally p r o v e n cases. T h e presence o r absence o f antirhizopus fimgistatic activity and antirhizopus antibody in the sera o f six o f the patients was correlated with the severity o f clinical disease. Preliminary results showed a relationship between the extent o f disease a n d the d e g r e e o f s e r u m fungistatic activity that was i n d e p e n d e n t o f antibody production.
Mucormycosis is tlm n a m e ascribed to infections caused by the usually n o n s e p t a t e fungi belonging to the class Zygomycetes (Phycomycetes). Historically, Paltauf ~ is credited with the first histologic description o f generalized mucormycosis in a 52 year old patient. Since this r e p o r t a p p e a r e d in 1885, opportunistic infections cattsed by fungi o f the o r d e r Mncor,des (genera Rifizol)tts, *lucor, a n d Absidia) have been recognized, usually at autopsy, in association with diabetes, hematologic nmlignant disease, imnmnosttppressive therapy, thermal burns, and surgery. -''s Mttcorntycosis rarely affects otherwise healthy p e o p l e ? In contrast, infections caused by fungi o f the related o r d e r E n t o m o p h t h o r a l e s (genera Basidiobo-
lus anti E n t o m o p h t h o r a ) typically involve the subcutaneous tissue o f healthy hosts. T h e s e infections have been r e p o r t e d principally in Asia and Afi'ica and either heal spontaneously o r respond to local treatment.S, G D u r i n g the last f o u r years a change in the spectrum o f disease, etiology, a n d diagtmsis o f m u c o r m y cosis has been recognized at T h e Mount Sinai Hospital. Althongh the r h i n o c e r e b r a l and p u l m o n a r y forms o f mucormycosis are still the nmst fl'equent forms o f the disease, hospital acquired cutaneous and subcutaneotts infections related principally to contaminated adhesive b a n d a g e have e m e r g e d as a newly appreciated s y n d r o m e . Patients with pttlmonary, cutaneous, and r h i n o c e r e b r a l mttcormycosis have been
Accepted for publication April 16, 1979. *I nstrnctor, Department of l'athology, The Mount Sinai School of Medicine, New York, New York. "['Associatel'rofessor, Department of Microbiology,Tile Mount Sinai Hospital, New York, New York. ~l'rofessor of Clinical l'athology, Department of l'athology, The Mount Sinai School of Medicine, New York, New York. w
in Microbiology,Department of Microbiology,The Mount Sinai ttospital, New York, New York. IIUMAN PATIIOI.OGY--VOI.UME 11, NUMBER 5, September1980
457
HUMAN I'ATHOLOGY-VOLUME 11, NUMBER 5 September 1980 diagnosed ahnost exclusively dr, ring life, resulting in a significant improvement in the survival rate with early treatment. Rlfizopus species, especially R. rhizopodoformis, have been the etiologic agents identified in 13 of 14 culturally proven cases. Tlais report concerns a 20 year experience with mucormycosis at our institution and serves to illustrate tile evolutionary trend in this highly invasive disease. MATERIAL AND METHODS
The autopsy and surgical patlmlogy records fl-om the Department of Pathology for the period 1958 througla 1978 were reviewed. Twenty-one postmortem and eight surgical specimens demonstrated histologic evidence of mucormycosis as evidenced by the presence of large, irregular, rarely septate hyphae with right angle branching in sections stained with hematoxylin and eosin or with methenamine silver. Records from tim Department of Microbiology reviewed for the period 1958 to 1978 revealed that 14 patients were diagnosed as having n!ucormycosis between 1974 and 1978. In each of the 14 instances diagnosis was made during life through examination of necrotic tissue obtained by scraping or by surgical intervention. Microscopic examination invariably revealed the broad, nonseptate (coenocytic), ribbon-like hyphae characteristic of a mucoraceous agent. Branching was usually right angled, and frequently the hyplml elements appeared collapsed and twisted. These morplmlogic features usually made possible the differentiation fi'om Aspergillus sp., which has smaller, clearly septate hyphae with branching at acute angles. Serum from six patients collected during active mucorxnycosis was assayed by immunodiffusion for precipitating antibodies to Absidia, Mucor, and Rlfizopus by Dr. Morris A. Gordon, New York State Department of Health, Albany, New York. In addition, the same sera were assayed for their capacity to retard tlm germination of Rhizopus spores, r' 8 With a
microdilution inethod, sera were diluted 5 to 50 per cent in 0.025 ml. of Sabouraud's broth after which 10~ freshly harvested R. rhizopodoformis spores were added to each well. After incubation at ambient temperature for 24 hours, microscopic evaluation of spore germination was recorded. Normal human sera were used as controls. Subsequent to tim development of postoperative mucormycotic skin infections in three patients within a two month period, environmental studies were nndertaken by exposing Sabouraud's agar plates for a minimum o f one hour at various locations in the surgical suites and intensive care units. Following the report of nosocomial Rhizopus infections associated with Elastoplast adhesive bandage, 'a cultures o f previously unopened rolls of Elastoplast obtained from the surgical intensive care units were also made? ~
RESULTS
The diagnosis o f mucormycosis was established in 32 patients. In contrast to the experience recorded at other institutions, mucormycosis has increased significantly in tile past four years, n During the first 16 )'ears of tiffs stud)', 17 cases were encountered and diagnosed solely at autopsy. Since 1974, however, 15 patients with mucormycosis were diagnosed ~ 14 (93 per cent) of these during life and only one patient after death (Fig. 1).
Clinicopathologic Correlations AcE A,XDSEX. The ages of patients rangedfrona 18 days to 78 years. Half were male. ASSOCIATED CONDITIONS. In our series diabetes (10 patients) and acute leukemia (10 patients) were the conditions most often associated with Mucorales infection; four patients developed the infection following a surgical procedure. Other conditions associated with this disease are noted in Figure 2. LAUORATOItV DATA. Eight of the 12 diabetic patients whose laboratory data were available devel-
6 oo 5 - ~ ! Posl-morlem diagnosis uJ or)
[ ] Diagnosis during life
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'63 '64 '65 '66 '67 '68 "69 '70 '71 '72 '73 '74 '75 '76 '77 '78
Figure 1. Incidence of nmcormycosis at Tile Mount Si,mi I lospital during the pe,iod 1958 to 1978.
MUCORMYCOSIS--MARCIIEVSKV ET AL.
TABLE 1.
MUCORMYCOSIS: C L I N I C A L A N D L A B O R A T O R Y P A R A M E T E R S IN 32 P A T I E N T S
Patient No.
Age/Sex
1 2 3 9t 5 6 7 8 9 10 11
36M 68F 67F 55M 65F 68M 78F 12F 32M 67M 36F
12
57M
13 14 15
55F 60F 49F
16 17 18 19 20 21
38F 58M 18 day old F 53M 71F ,t 8F
22 23
Anatomic Site of Involvement
Underlying Disease
Diagnostic Procedure
Species Isolated
Acute myclogenous leukemia Diabetes mellitus, miliary tuberculosis Diabetes mellitus, carcinoma of uterus Mitral steuosis, valve replacement Acute myelogenous leukemia Diabetes, nephrotic syndrome Diabetes, acute myelogenous leukemia Diabetes Acute myeloxnonoc)tic leukemia Acute xn)'elogenous let, kemia Breast carcinoma
Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy
None None None None None None None None None None None
No No No No No No No No No No No
Augina, triple coronary bypass, thrombocytopenia (Pronestyl related)
Autopsy
None
No
Autopsy Autopsy Autopsy
None None None
No No No
Larynx, stomach Colon Jugular vein
Macroglobulinemia Carcinoma of ovary Cushing's disease, diabetes, basal squamous cell carcinoma of skin Ulcerative colitis Diverticulitis, colonic resection i'rematurity
Autopsy Autopsy Autopsy
None Nnne None
No No No
Rhinocerebral Orbital Orbital
Renal transplant Diabetes mellitus Diabetes mellitus
R. an hizus R. arrhizus R. arrhizus
No No Yes
58F 55F
Orbital Facial cellulitis
Diabetes mellitus Acute lymphocytic leukemia
49M .t9M 14M
Orbital Perinasal, orbital Perinasal, orbital
Acute myelogenous leukemia Acute myelogenous leukemia Acute lymphocytic leukemia
R. arrhizus ..Ibsidiacmymbifera Rhizopus sp. R: rhizopodoformis Rhizopus sp.
Yes No
24 25 26 27
25F
Orbital
Diabetes mellitus
Failed to grow
Yes
28
54M
Skin
Acute myelogenons leukemia
30M
30
67M
Skin and subcutaRenal transplant neous tissue over renal biopsy tract Skin Cardiac surgery
R. rhizopodoformis R. rhizopodofonnis
No
29
Sinus biopsy Nasal biopsy Biopsy of ethmoidal sinus Palatal biopsy Scraping from lip lesion Nasal biopsy Nasal biopsy Scraping from palate Necrotic tissue from sinus Scraping from eschar Biopsy of necrotic subcutaneous tissue Skin biopsy
31
,t5M
Lung
Renal transplant
32
49M
l.ung
Acute myelogenous leukemia
Rhinocerebral Rhinocerebral Rhinocerebral Lung l.ung Lung, spleen Lung Lung Lung Luqg l.ung, small intestine Skin of chest wall, thoracic outlet vessels, hmg Jejumml I.ung, spleen Esophagus
Bronchoscopic aspirate and biopsy Percutaneous lung biopsy
R. ~hizopodoformis R. rhizopodoformis R. rhizopodoformis
Survival
No No No
Yes Yes Yes No
459
IIUMAN PATHOLOGY--VOI.UME 11, NUMBER 5 September 1980 Cushing's syndrome Ulcerative colitis / Immaturity \ Diverticu MacrocJIobulinemic Chronic lymphocytic leukemia
)iabetes mellitus
Cardiac su rgery----.
Figure 2. Associated underlying conditions in 32 patients with mucormycosis.
Renal transplant -"
Corcinon
\ Acute leukemia
aped mucormycosis after the onset of severe hyperglycemia or ketoacidosis. Anemia was the single most common laboratory finding in the 32 patients. Anatomic Involvement
Disseminated mucormycosis, as j u d g e d by multiorgan involvement, was encountered in four of the 32 patients. The organ most often involved was the lung (12 cases). Rlfinocerebral mucormycosis was diagnosed in nine instances, and skin and subcutaneous tissue were involved in four patients. As noted in Table 2, a variety of other organs were invaded. LuNc,s. Ten of the 12 patients with pulmonary mucormycosis were diagnosed at autopsy, whereas two were diagnosed during life, one by percutaneous needle biopsy and the other by bronchoscopic biopsy. T h e latter patient underwent lobectomy of the affected hmg, There was no affinity for a particular lobe or hmg in this series. Grossly, three distinct varieties of pulmonary involvement were recognized. In nine cases the hmgs were congested, with muhiple loci of hemorrhage; in two of these, grossly visible thrombi were found in pulmonary arteries. Small 1 to 2 cm. wedge shaped infarcts were present in both lungs of one patient. Abscesses were noted in the lobectomy specimen, as well as in three other hmgs examined at autopsy;
TABLE 2. MUCORMYCOSIS: ORGAN INVOLVEMENT IN 32 PATIENTS, THE MOUNT SINAI HOSPITAL (1958-1978) Organ(s) l.ungs Rhinocerebral Skin and subcutaneous tissue Spleen Stomach Jejunum Colon, esophagus, larynx, jugular vein, eye
460
No. of Patients 12 12 4 2 2 2 l each
tllese were 2 to 8 cm. in diameter, lined by shaggy gray membranes, and surrounded by hemorrllagic parenchyma. In one case the abscess invoh'ed a branch of the puhnonary artery and resulted in a mycotic aneurysm that rnptnred, producing massive hemoptysis. Microscopically, hemorrhagic areas showed many large nonseptate hyphae growing in and around small blood vessels and extending into the surrotmding parenclwma. Thrombtts formation with tangled fungal masses leading to vascular occlusion was present in all cases, and foci of hemorrlmgic infarction were common. An acute inflammatory reaction was present but was generally scanty. In two patients foreign body type granulomas were seen; in one of these hypllal fi'agments were observed within giant cells (Fig. 3). SKIN AND SURCUTANI':OUS TISSUE. The skin was invoh'ed in four patients. Biopsy specimens fi'om three of these patients and tissue obtained at autopsy from the fourth were studied. Two patients had large 6 by 6 cm. indurated eschars, which appeared on the chest wall eight to 12 days after cardiac surgery. Biopsy and cuhure o f one o f these lesions revealed R. rhizopodoformis. Local application of amphotericin B resuhed in complete healing. The chest wall lesion of the second patient progressed rapidly to become a large ulceration with necrotizing cellulitis extending from the anterior chest into the mediastiniam and neck. Culture of repeated specimens of wound pus collected on a swab grew several bacterial species but were negative for flmgi. A biopsy was not performed. The patient expired. At atttopsy the carotid arteries were found to be thrombosed anti infihrated by hyphae, and the right hmg had al ! apical abscess tlmt microscopically showed extensive invasion with mucormycotic hypime. A third patient developed a sinus tract infection two weeks after needle biopsy of the left kidney undertaken to determine the nature of renal insufficiency following rejection o f a transplant. Direct microscopic examination of resected tissue
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lb.,
I
..
Av Figure 3. Granuloma with foreign body multinucleated giant cell containing rarel) observed phagocytized mucorm)'cotic h)'phal element. Note also more common presence of hyphae in the surrounding inflammatory exudate. (! lematoxylin and eosin stain, x400.)
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:
4:
Figure 4, Ecth)ma gangrenosuna. H, Broad nonseptate h)'phae characteristic of a inucormycotic agent observed on direct microscopic examination of biopsy specimen from skin lesion (B).-Tile patient (number 28) had acute myelogeoous leukemia.
461
IIUMAN
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showed multiple mucoraceous hyphae; cultures grew
R. rhizopodoformis. The kidney was removed and demonstrated massive rejection, but no fungi were observed in multiple histologic sections. Administration of amphotericin B resulted in improvement. The fourth patient with ct, taneous mucormycosis had acute myelogenous leukemia. A clinical diagnosis of ecthyma gangrenosum was made. Biopsy and culture of the periphery of a skin lesion failed to reveal either bacteria or fimgi. Curettings o f the necrotic center, however, were examined microscopicall}' and showed numerous mucormycotic flmgal elements (Fig. 4). R. rhizopodoformis was recovered on culture. Chest x-ray examination revealed pulmonary infiltrates. The patient died the following day, but autopsy was not performed. RIIINOCEREBRAL INFECTION. h i nine patients tlmre was involvemem of the paranasal sinuses. Invasion of the orbit followed in four and the brain in four. Cavernous si,ms invasion with thrombosis occurred in two, and an eye was invoh'ed in one instance. Four patients lind palatal lesions. Typically patients presented with fever, facial or orbital cellulitis, and a black indurated eschar (Fig. 5). Microscopic examination demonstrated extensive ne-
Figure 5. Nasal irmcorm)cosis with bilateral necrotic eschar from xdfich I?. rhizopodoformi~was recovered. The patient (number 25) had acute In)elogellous leukemia.
462
September 1980
crosis, a scanty acute inflammatory reaction, and hyphae growing into necrotic tissue with widespread invasion of small blood vessels. Foreign body type granulomas were observed in one case. Scrapings and biopsy material from eight of these patients grew Rhizopus species (Table 1).
Mycology Cnhure of necrotic material yielded the rancormycotic agent in 13 of the 14 cases diagnosed during life. Isolation was achieved by implanting tissue fragments directly onto 5 per cent sheep blood (BBL) and Sabourand's dextrose agar and incnbating at 37 ~ C. Growth usually ensued within 2,t hours in the form of delicate streaming Iwphal elements coursing along the agar surface. The presence of associated bacterial species in the clinical specimen often delayed growth tmtil 36 to 48 hours. After this incubation period, black speckled hyplml elements extended from the agar surface to the lid of the Petri dish and usually enveloped the entire surface of the medimn. Ascription of an isolate to a genus of Mucoraceae usually associated with lmman mucormycosis (Absidia, Mucor, Rhizopus) was achieved by microscopic exanfination of teased lwphai elements to determine the morphologic origin of the stalklike sporangiophores, which bear the spore laden sporangia. With Absidia, the sporangiophores arise from aerial hyphae (stolons) between clusters of rootlike projections (rhizoids), whereas with Rhizopus, the sporangiophorcs emanate singly or in nmltiples directly from a cluster of rhizoids. T h e latter holdfasts are absent in Mucor, in which the sporgiophores arise directly fi'om vegetative nonseptate hyphae. On the basis o f the pfcceding criteria, 12 isolates were identified as Rhizopus and one as Absidia." Definitive speciation of the isolates was achieved througll the courtesy of Dr. John Ellis, Northern Regional Research Laboratory, U.S. Departinent of Agriculture, I'coria, Illinois, and Dr. Irene Weitzman, New York City Department of Health (Table 1). Serologically, four of the six sera assayed formed precipitin bands with the Rbizopus antigen only (Table 3). Two of these sera were derived from patients (numbers 29 and 30) with therapy responsive subcntaneous mucormycotic infection due to R. rhizopodoformis. The rexnaining two reactive sera were obtained from patients with leukemia (nunlbers .25 and 26) who developed fatal rhinocerebral disease. Tim two nonreactive sera were from patients (numbers 31 and 32) with puhnonary R. rhizopodoform/s infection, one of whom responded to therapy. Two of the six sera assayed for antifungal activity completely failed to inhibit the g r o w t h o f the test R. rhizopodoformis even when undiluted. These two sei'a, obtained from leukenfic patients 25 and 26, also demonstrated precipitin antibody to Rhizopus. T h e sera of the remaining four patients (nnmbers 29, 30, 31, and 32) with mucormycosis did demonstrate some fungal inhibitory activity, which occurred in sera
MUCORM YCOSIS- ,MARC!IEVSKYET AL. TABLE 3. MUCORMYCOSIS: C O R R E L A T I O N BETWEEN SERUM A N T I B O D Y LEVELS, SERUM F U N G I S T A T I C A C T I V I T Y , A N D O U T C O M E OF I N F E C T I O N * % S e r u m Required
Patient
Organ Involved
Presence of Precipitin
for Fungistatie Activity No inlfibition in undiluted serum No inhibition in undiluted serum 20-30% 20-30% 20-30% 20-30%'I" No inhibition in undiluted seru rll ~"
No.
Underlying Disease
25
Acute m)elogeuous leukemia
Orbit
+
26
Acute lymphocytic leukemia
Orbit
+
29 30 31 32
Surgery Renal transplant Acute myelogenous leukemia Acute myclogenous leukemia
Skin Skin Lung Lung
+ + 0 0 0
Normal
0
Outcome Died Died Survived Survived Survived Survived
5%
*As determined by the microdilution method of Kerbs et al. ~5 t S c r u m assayed six weeks later, just prior to patient's death. T h e mucormycotic abscess was still present in lung.
diluted to 20 to-30 per cent concentration. Patient 32 expired six weeks after the initial diagnosis. A second serum specimen collected just prior to death lacked fungistatic activity. Normal sera, in contrast, inhibited growtla o f the same R. rhizopodoformis spore suspenstun even after dilution to 5 per cent of the original concentration. In the environmental studies, exposed Petri dishes containing Sabouraud's agar demonstrated the presence of fimgal species such as Aspergillus, Penicillium, and Syncephalastrum, but were devoid of Mucoraceae. However, cultures of unopened Elastoplast adhesive bandage obtained from the surgical intensive care unit did grow out R. rhizopodoformis, io DISCUSSION
Mttcormycotic agents are found througllotat the world on fl-uit and bread, in air, and in soil where they exist as saprophytes. Rhinocerebral infection results from inimlation of airborne spores. In the nasal mucosa germination ensues and the hyphal elements penetrate by direct extension or througla vascular channels to the paranasal sinuses, orbit, brain, and occasionally even the eye. Pulmonary invasion results from either hematogenous spread fl-om a distal focus or airborne acquisition of spores.-", a l'uimonary infections still present the most difficult diagnostic challenge. In our series only two o f 12 .patients were diagnosed during life. In these two instances puhnonary fungal infection was strongly suspected clinically, and the diagnosis was achieved by observing the mucormycotic agent in specimens obtained by fiberoptic bronchoscopy and percutaneous needle lung biopsy. Both patients improved with treatment; one tmderwent lobectomy in addition to treatment with amphotericin B and the second received amphotericin B only. In contrast to prior reports, grossly distinct lesions of nmcorm)'cosis were rarely observed. '2. ta Indeed only one of the 10 pa-
tients examined at necropsy had grossly recognizable pulmonary infarction with vascular thrombosis. Similarly, nmcormycotic invasion of organs other than the lung was often grossly indistinct. Histologicall}', with one exception, typical a r e a s o f coagulative and llemorrhagic necrosis with ftmgal hyphae, moderate sttppurative inflammation, and vascular thrombi were observed. Foreign body type granulomas were present in three instances, once in the nose and twice in the hmg. A granulomatous response has been noted previously, ta In our experience mucormycotic foreign body type grantflomas differ fi'om epithelioid cell granulomas as seen in tuberculosis and other fimgal infections. T h e granulomas described in patients with subcutaneous Entomophthoraceae infection are also different, with epithelioid cells and a conspicuous eosinophilic component. 6 Nosocomial acquisition of a nmcormycotic infection has long been suspected but seldom documented. In this stud)' nosocomial contraction of mucormycosis was postulated in four patients. In the newborn (patient 18) with jugular vein involvement only, a catheter inserted into this vein may have served as the portal of entry of the fimgus. In three o f four patients (numbers 12, 29, and 30) with cutaneous and subcutaneous nmcormycosis caused by R. rhizopodoformis, infection followed a surgical procedure. In two of these patients (nnmbers 12 and 30) and possibly the third (number 29) Elastoplast adhesive bandage was applied over the site of the original lesions. R. rhizopodoformis was isolated from unopened Elastoplast bandages derived from the cardiac intensive care unit tltat housed patients 12 and 30.t~ Four of six patients with mucorinycosis respondcd to the inciting agent with an antibody response to Rhizopus. Altllough normal serum diluted to 5 per cent inhibited the gernfination of Rhizopus spores, the sera from the two leukemic patients (numbers 25 and 26) with orbital involvement lacked such flmgistatic activity even in the undiluted state and in the presence of anti-Rhizoptls antibody. The remaining four sera (patients 29, 30, 31, and 32) showed re-
463
H U M A N I ' A T I I O L O G Y - - V O L U M E 11, NUMBER 5 d t t c e d flmgistasis; at 20 to 30 p e r c e n t s e r u m c o n c e n t r a t i o n s inltibitory activity was absent.
T h e presence of serum antibody did not appear to influence germination of Rhizopus spores. Two of the sera that lacked flmgistatic activity did have anti-Rhizopus precipitins, but two additional sera lacking antibody demonstrated antifungal activity, although reduced. In this study a correlation was shown between tlte severity of the disease and the degree of serum fungistatic activity, irrespective of the presence of antibody. Patients 25 and 26 whose undihtted sera lacked inhibitory activity had a fiflminating fatal disease. Patients 29, 30, and 31 whose sera showed reduced initibitory activity had a more benign and therapeutically responsive disease. I'atient 32, wltose initial serum showed reduced fungistatic activity, had a six week clinical course with radiologic evidence of improvement of puhnonary mucormycosis. Noteworthy, however, was the disappearance of serum fungistatic activity just prior to death. Autopsy revealed an 8 cm. mucormycotic pulmonary abscess. Systemic invasion had not occurred. Continued clinical and serologic correlation is needed to bring into sharper focus t h e r o l e of serum fimgistasis as a prognostic guide. Whereas the presence of antibody may be diagnostic, the failure to demonstrate in vitro flmgistasis with the sera of potentially susceptible hosts may be of prognostic value.
ACKNOWLEDGMENTS Ludwig M. Deppisch, M.D., initiated this study and generottsly provided his resuhs for our use. T h e attthors wish to recognize Patrick Molt, M.D., a n d Allan N. Schwartz, M.D., because of their awareness of the need for clinical and laboratory correlation.
September 1980 Dr. Gigcr is a recipient of a grant from Analytab Products, Inc. (API), Plainview, New York. Olga Duff provided excellent secretarial assistance.
REFERENCES !. Pahauf, A.: Mycosis mncorina. Virchows Arch. I'ath. Anat., 102:543, 1885. 2. Baker, R. D. (Editor): Human Infections with Fungi, Actiuom)cetes and Algae. New York, Springer-Verlag, 1971, p. 832. 3. Rosen, P.: Opportunistic fimgal infections in patients with neoplastic disease, l'athol. Ann., 11:255, 1976. 9t. Singh,J., and Prasanna, N. M.: Phycomycosis in an apparently normal host. J. Otolar}'ngoI., 6:37, 1977. 5. Williams, A. O.: Pathology of phycomycosis due to Entomophtora and Basidiobolus species. Arch. l'athol., 87:13, 1969. 6. Clark, B. M., and Edington, E. G.: Subcutaneous phycomycosis and rhino-entomophthorom)cosis.I , Baker, R. D. (Editor): lluman Infections with Fungi, Actinom)cetes and Algae. New York, Springer-Verlag, 1971, p. 684. 7. Gale, G. R., and Welch, A. M.: Studies of opportunistic fungi: inhibition of Rhizopus oryzae by human serum. Am. J. Med. Sci., 241:604, 1961. 8. Owens, A. W., Schacklette, M. H., and Baker, R. D.: Antifungal factor in serum. I. Studies on Rhizopus rhizopodoformis. Sabouraudia, 4:179, 1965. 9. Keys,T. F., et al.: Nosocomial outbreak of Rhizopus infections associated with Elastoplast wound dressing. Minn. Mort. Morb. Wkl)'. Rep., 27:33, 1978. 10. Gartenberg, G., et al.: Hospital acquired nlucormycosis (Rhizopus rhisopodoformiO of skin and subcutaneous tissue: epidemiology, mycology and treatment. New Eng. J. Med., 299: 115, 1978. 11. Rosen, P.: Decreased frequency ofaspergillosis and mucormycosts (letter). New Eng. J. Med., 295:1319, 1976. 12. Medoff, G., and Kobayashi, G. S.: Pulmonary mucorm)cosis. New Eng. J. Mcd., 286:86, 1972. 13. Baker, R. D.: Pulmonary mucorinycosis. Amer. j. l'athol., 32:287, 1956. 14. Leong, A. S. Y.: Grantflomatous mcdiastinitis due to Rhizopus spccies. Amer. J. Clin. Pathol., 70:103, 1978. 15. Kerbs, S., Huttou, R. D., and Hollister, J. W.: Visual micromethod for assay of fnngal growth. Can. J. Microbiol., 24:574, 1978. Department of l'athology The Mount Sinai tlospital One Gustave Levy Place New York, New York 10029 (Dr. Marchevsky)
464
E T AL.
57. Qizilbash, A., et al.: Functioning primary carcinoid tumor of the ovary. Am. J. Clin. Path., 62:629, 197.t. 58. Stoebner, P., et al.: Ultrastructure of anaplastic bronchial carcinomas. Cancer, 20:286, 1967. Department of Pathology and Area Laboratory Services Brooke Arm)" Medical Center Fort Sam ltot,ston, Texas 78234 (Dr. Herrera)
THE C H A N G I N G SPECTRUM OF DISEASE, ETIOLOGY, A N D D I A G N O S I S OF MUCORMYCOSIS Alberto M. Marchevsky, M.D.,* Edward J. Bottone, Ph.D.,t Stephen A. Gelled, M.D.,$ and Donald K. Gige~, Ph.D.w Abstract During tim 20 year interval f r o m 1958 t h r o u g h 1978 a c h a n g e in the spectrum o f disease, etiology, a n d diagnosis o f mucormycosis was observed at T h e M o u n t Sinai Hospital. Alflmugh the rltinocerebral and p u l m o n a r y forms o f mucormycosis were still the most f r e q u e n t forms o f disease, hospital acqtfired c u t a n e o u s and subcntaneous infections emerged. Since 1974, 14 o f 15 cases o f mucormycosis were diagnosed d u r i n g life. Rhizopus species, especially R. rhizopodoformis, have been the etiologic agents identified in 13 o f 14 cuhurally p r o v e n cases. T h e presence o r absence o f antirhizopus fimgistatic activity and antirhizopus antibody in the sera o f six o f the patients was correlated with the severity o f clinical disease. Preliminary results showed a relationship between the extent o f disease a n d the d e g r e e o f s e r u m fungistatic activity that was i n d e p e n d e n t o f antibody production.
Mucormycosis is tlm n a m e ascribed to infections caused by the usually n o n s e p t a t e fungi belonging to the class Zygomycetes (Phycomycetes). Historically, Paltauf ~ is credited with the first histologic description o f generalized mucormycosis in a 52 year old patient. Since this r e p o r t a p p e a r e d in 1885, opportunistic infections cattsed by fungi o f the o r d e r Mncor,des (genera Rifizol)tts, *lucor, a n d Absidia) have been recognized, usually at autopsy, in association with diabetes, hematologic nmlignant disease, imnmnosttppressive therapy, thermal burns, and surgery. -''s Mttcorntycosis rarely affects otherwise healthy p e o p l e ? In contrast, infections caused by fungi o f the related o r d e r E n t o m o p h t h o r a l e s (genera Basidiobo-
lus anti E n t o m o p h t h o r a ) typically involve the subcutaneous tissue o f healthy hosts. T h e s e infections have been r e p o r t e d principally in Asia and Afi'ica and either heal spontaneously o r respond to local treatment.S, G D u r i n g the last f o u r years a change in the spectrum o f disease, etiology, a n d diagtmsis o f m u c o r m y cosis has been recognized at T h e Mount Sinai Hospital. Althongh the r h i n o c e r e b r a l and p u l m o n a r y forms o f mucormycosis are still the nmst fl'equent forms o f the disease, hospital acquired cutaneous and subcutaneotts infections related principally to contaminated adhesive b a n d a g e have e m e r g e d as a newly appreciated s y n d r o m e . Patients with pttlmonary, cutaneous, and r h i n o c e r e b r a l mttcormycosis have been
Accepted for publication April 16, 1979. *I nstrnctor, Department of l'athology, The Mount Sinai School of Medicine, New York, New York. "['Associatel'rofessor, Department of Microbiology,Tile Mount Sinai Hospital, New York, New York. ~l'rofessor of Clinical l'athology, Department of l'athology, The Mount Sinai School of Medicine, New York, New York. w
in Microbiology,Department of Microbiology,The Mount Sinai ttospital, New York, New York. IIUMAN PATIIOI.OGY--VOI.UME 11, NUMBER 5, September1980
457
HUMAN I'ATHOLOGY-VOLUME 11, NUMBER 5 September 1980 diagnosed ahnost exclusively dr, ring life, resulting in a significant improvement in the survival rate with early treatment. Rlfizopus species, especially R. rhizopodoformis, have been the etiologic agents identified in 13 of 14 culturally proven cases. Tlais report concerns a 20 year experience with mucormycosis at our institution and serves to illustrate tile evolutionary trend in this highly invasive disease. MATERIAL AND METHODS
The autopsy and surgical patlmlogy records fl-om the Department of Pathology for the period 1958 througla 1978 were reviewed. Twenty-one postmortem and eight surgical specimens demonstrated histologic evidence of mucormycosis as evidenced by the presence of large, irregular, rarely septate hyphae with right angle branching in sections stained with hematoxylin and eosin or with methenamine silver. Records from tim Department of Microbiology reviewed for the period 1958 to 1978 revealed that 14 patients were diagnosed as having n!ucormycosis between 1974 and 1978. In each of the 14 instances diagnosis was made during life through examination of necrotic tissue obtained by scraping or by surgical intervention. Microscopic examination invariably revealed the broad, nonseptate (coenocytic), ribbon-like hyphae characteristic of a mucoraceous agent. Branching was usually right angled, and frequently the hyplml elements appeared collapsed and twisted. These morplmlogic features usually made possible the differentiation fi'om Aspergillus sp., which has smaller, clearly septate hyphae with branching at acute angles. Serum from six patients collected during active mucorxnycosis was assayed by immunodiffusion for precipitating antibodies to Absidia, Mucor, and Rlfizopus by Dr. Morris A. Gordon, New York State Department of Health, Albany, New York. In addition, the same sera were assayed for their capacity to retard tlm germination of Rhizopus spores, r' 8 With a
microdilution inethod, sera were diluted 5 to 50 per cent in 0.025 ml. of Sabouraud's broth after which 10~ freshly harvested R. rhizopodoformis spores were added to each well. After incubation at ambient temperature for 24 hours, microscopic evaluation of spore germination was recorded. Normal human sera were used as controls. Subsequent to tim development of postoperative mucormycotic skin infections in three patients within a two month period, environmental studies were nndertaken by exposing Sabouraud's agar plates for a minimum o f one hour at various locations in the surgical suites and intensive care units. Following the report of nosocomial Rhizopus infections associated with Elastoplast adhesive bandage, 'a cultures o f previously unopened rolls of Elastoplast obtained from the surgical intensive care units were also made? ~
RESULTS
The diagnosis o f mucormycosis was established in 32 patients. In contrast to the experience recorded at other institutions, mucormycosis has increased significantly in tile past four years, n During the first 16 )'ears of tiffs stud)', 17 cases were encountered and diagnosed solely at autopsy. Since 1974, however, 15 patients with mucormycosis were diagnosed ~ 14 (93 per cent) of these during life and only one patient after death (Fig. 1).
Clinicopathologic Correlations AcE A,XDSEX. The ages of patients rangedfrona 18 days to 78 years. Half were male. ASSOCIATED CONDITIONS. In our series diabetes (10 patients) and acute leukemia (10 patients) were the conditions most often associated with Mucorales infection; four patients developed the infection following a surgical procedure. Other conditions associated with this disease are noted in Figure 2. LAUORATOItV DATA. Eight of the 12 diabetic patients whose laboratory data were available devel-
6 oo 5 - ~ ! Posl-morlem diagnosis uJ or)
[ ] Diagnosis during life
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illi
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o 3-
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i i iI
=
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I
0 458
'63 '64 '65 '66 '67 '68 "69 '70 '71 '72 '73 '74 '75 '76 '77 '78
Figure 1. Incidence of nmcormycosis at Tile Mount Si,mi I lospital during the pe,iod 1958 to 1978.
MUCORMYCOSIS--MARCIIEVSKV ET AL.
TABLE 1.
MUCORMYCOSIS: C L I N I C A L A N D L A B O R A T O R Y P A R A M E T E R S IN 32 P A T I E N T S
Patient No.
Age/Sex
1 2 3 9t 5 6 7 8 9 10 11
36M 68F 67F 55M 65F 68M 78F 12F 32M 67M 36F
12
57M
13 14 15
55F 60F 49F
16 17 18 19 20 21
38F 58M 18 day old F 53M 71F ,t 8F
22 23
Anatomic Site of Involvement
Underlying Disease
Diagnostic Procedure
Species Isolated
Acute myclogenous leukemia Diabetes mellitus, miliary tuberculosis Diabetes mellitus, carcinoma of uterus Mitral steuosis, valve replacement Acute myelogenous leukemia Diabetes, nephrotic syndrome Diabetes, acute myelogenous leukemia Diabetes Acute myeloxnonoc)tic leukemia Acute xn)'elogenous let, kemia Breast carcinoma
Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy
None None None None None None None None None None None
No No No No No No No No No No No
Augina, triple coronary bypass, thrombocytopenia (Pronestyl related)
Autopsy
None
No
Autopsy Autopsy Autopsy
None None None
No No No
Larynx, stomach Colon Jugular vein
Macroglobulinemia Carcinoma of ovary Cushing's disease, diabetes, basal squamous cell carcinoma of skin Ulcerative colitis Diverticulitis, colonic resection i'rematurity
Autopsy Autopsy Autopsy
None Nnne None
No No No
Rhinocerebral Orbital Orbital
Renal transplant Diabetes mellitus Diabetes mellitus
R. an hizus R. arrhizus R. arrhizus
No No Yes
58F 55F
Orbital Facial cellulitis
Diabetes mellitus Acute lymphocytic leukemia
49M .t9M 14M
Orbital Perinasal, orbital Perinasal, orbital
Acute myelogenous leukemia Acute myelogenous leukemia Acute lymphocytic leukemia
R. arrhizus ..Ibsidiacmymbifera Rhizopus sp. R: rhizopodoformis Rhizopus sp.
Yes No
24 25 26 27
25F
Orbital
Diabetes mellitus
Failed to grow
Yes
28
54M
Skin
Acute myelogenons leukemia
30M
30
67M
Skin and subcutaRenal transplant neous tissue over renal biopsy tract Skin Cardiac surgery
R. rhizopodoformis R. rhizopodofonnis
No
29
Sinus biopsy Nasal biopsy Biopsy of ethmoidal sinus Palatal biopsy Scraping from lip lesion Nasal biopsy Nasal biopsy Scraping from palate Necrotic tissue from sinus Scraping from eschar Biopsy of necrotic subcutaneous tissue Skin biopsy
31
,t5M
Lung
Renal transplant
32
49M
l.ung
Acute myelogenous leukemia
Rhinocerebral Rhinocerebral Rhinocerebral Lung l.ung Lung, spleen Lung Lung Lung Luqg l.ung, small intestine Skin of chest wall, thoracic outlet vessels, hmg Jejumml I.ung, spleen Esophagus
Bronchoscopic aspirate and biopsy Percutaneous lung biopsy
R. ~hizopodoformis R. rhizopodoformis R. rhizopodoformis
Survival
No No No
Yes Yes Yes No
459
IIUMAN PATHOLOGY--VOI.UME 11, NUMBER 5 September 1980 Cushing's syndrome Ulcerative colitis / Immaturity \ Diverticu MacrocJIobulinemic Chronic lymphocytic leukemia
)iabetes mellitus
Cardiac su rgery----.
Figure 2. Associated underlying conditions in 32 patients with mucormycosis.
Renal transplant -"
Corcinon
\ Acute leukemia
aped mucormycosis after the onset of severe hyperglycemia or ketoacidosis. Anemia was the single most common laboratory finding in the 32 patients. Anatomic Involvement
Disseminated mucormycosis, as j u d g e d by multiorgan involvement, was encountered in four of the 32 patients. The organ most often involved was the lung (12 cases). Rlfinocerebral mucormycosis was diagnosed in nine instances, and skin and subcutaneous tissue were involved in four patients. As noted in Table 2, a variety of other organs were invaded. LuNc,s. Ten of the 12 patients with pulmonary mucormycosis were diagnosed at autopsy, whereas two were diagnosed during life, one by percutaneous needle biopsy and the other by bronchoscopic biopsy. T h e latter patient underwent lobectomy of the affected hmg, There was no affinity for a particular lobe or hmg in this series. Grossly, three distinct varieties of pulmonary involvement were recognized. In nine cases the hmgs were congested, with muhiple loci of hemorrhage; in two of these, grossly visible thrombi were found in pulmonary arteries. Small 1 to 2 cm. wedge shaped infarcts were present in both lungs of one patient. Abscesses were noted in the lobectomy specimen, as well as in three other hmgs examined at autopsy;
TABLE 2. MUCORMYCOSIS: ORGAN INVOLVEMENT IN 32 PATIENTS, THE MOUNT SINAI HOSPITAL (1958-1978) Organ(s) l.ungs Rhinocerebral Skin and subcutaneous tissue Spleen Stomach Jejunum Colon, esophagus, larynx, jugular vein, eye
460
No. of Patients 12 12 4 2 2 2 l each
tllese were 2 to 8 cm. in diameter, lined by shaggy gray membranes, and surrounded by hemorrllagic parenchyma. In one case the abscess invoh'ed a branch of the puhnonary artery and resulted in a mycotic aneurysm that rnptnred, producing massive hemoptysis. Microscopically, hemorrhagic areas showed many large nonseptate hyphae growing in and around small blood vessels and extending into the surrotmding parenclwma. Thrombtts formation with tangled fungal masses leading to vascular occlusion was present in all cases, and foci of hemorrlmgic infarction were common. An acute inflammatory reaction was present but was generally scanty. In two patients foreign body type granulomas were seen; in one of these hypllal fi'agments were observed within giant cells (Fig. 3). SKIN AND SURCUTANI':OUS TISSUE. The skin was invoh'ed in four patients. Biopsy specimens fi'om three of these patients and tissue obtained at autopsy from the fourth were studied. Two patients had large 6 by 6 cm. indurated eschars, which appeared on the chest wall eight to 12 days after cardiac surgery. Biopsy and cuhure o f one o f these lesions revealed R. rhizopodoformis. Local application of amphotericin B resuhed in complete healing. The chest wall lesion of the second patient progressed rapidly to become a large ulceration with necrotizing cellulitis extending from the anterior chest into the mediastiniam and neck. Culture of repeated specimens of wound pus collected on a swab grew several bacterial species but were negative for flmgi. A biopsy was not performed. The patient expired. At atttopsy the carotid arteries were found to be thrombosed anti infihrated by hyphae, and the right hmg had al ! apical abscess tlmt microscopically showed extensive invasion with mucormycotic hypime. A third patient developed a sinus tract infection two weeks after needle biopsy of the left kidney undertaken to determine the nature of renal insufficiency following rejection o f a transplant. Direct microscopic examination of resected tissue
~0 9
I~"
,ID
lb.,
I
..
Av Figure 3. Granuloma with foreign body multinucleated giant cell containing rarel) observed phagocytized mucorm)'cotic h)'phal element. Note also more common presence of hyphae in the surrounding inflammatory exudate. (! lematoxylin and eosin stain, x400.)
t:j
.~.
,
,
il, I
_ t* p
r h
1'
:
4:
Figure 4, Ecth)ma gangrenosuna. H, Broad nonseptate h)'phae characteristic of a inucormycotic agent observed on direct microscopic examination of biopsy specimen from skin lesion (B).-Tile patient (number 28) had acute myelogeoous leukemia.
461
IIUMAN
I'ATttOLOGY-VOLUME
11, N U M B E R
5
showed multiple mucoraceous hyphae; cultures grew
R. rhizopodoformis. The kidney was removed and demonstrated massive rejection, but no fungi were observed in multiple histologic sections. Administration of amphotericin B resulted in improvement. The fourth patient with ct, taneous mucormycosis had acute myelogenous leukemia. A clinical diagnosis of ecthyma gangrenosum was made. Biopsy and culture of the periphery of a skin lesion failed to reveal either bacteria or fimgi. Curettings o f the necrotic center, however, were examined microscopicall}' and showed numerous mucormycotic flmgal elements (Fig. 4). R. rhizopodoformis was recovered on culture. Chest x-ray examination revealed pulmonary infiltrates. The patient died the following day, but autopsy was not performed. RIIINOCEREBRAL INFECTION. h i nine patients tlmre was involvemem of the paranasal sinuses. Invasion of the orbit followed in four and the brain in four. Cavernous si,ms invasion with thrombosis occurred in two, and an eye was invoh'ed in one instance. Four patients lind palatal lesions. Typically patients presented with fever, facial or orbital cellulitis, and a black indurated eschar (Fig. 5). Microscopic examination demonstrated extensive ne-
Figure 5. Nasal irmcorm)cosis with bilateral necrotic eschar from xdfich I?. rhizopodoformi~was recovered. The patient (number 25) had acute In)elogellous leukemia.
462
September 1980
crosis, a scanty acute inflammatory reaction, and hyphae growing into necrotic tissue with widespread invasion of small blood vessels. Foreign body type granulomas were observed in one case. Scrapings and biopsy material from eight of these patients grew Rhizopus species (Table 1).
Mycology Cnhure of necrotic material yielded the rancormycotic agent in 13 of the 14 cases diagnosed during life. Isolation was achieved by implanting tissue fragments directly onto 5 per cent sheep blood (BBL) and Sabourand's dextrose agar and incnbating at 37 ~ C. Growth usually ensued within 2,t hours in the form of delicate streaming Iwphal elements coursing along the agar surface. The presence of associated bacterial species in the clinical specimen often delayed growth tmtil 36 to 48 hours. After this incubation period, black speckled hyplml elements extended from the agar surface to the lid of the Petri dish and usually enveloped the entire surface of the medimn. Ascription of an isolate to a genus of Mucoraceae usually associated with lmman mucormycosis (Absidia, Mucor, Rhizopus) was achieved by microscopic exanfination of teased lwphai elements to determine the morphologic origin of the stalklike sporangiophores, which bear the spore laden sporangia. With Absidia, the sporangiophores arise from aerial hyphae (stolons) between clusters of rootlike projections (rhizoids), whereas with Rhizopus, the sporangiophorcs emanate singly or in nmltiples directly from a cluster of rhizoids. T h e latter holdfasts are absent in Mucor, in which the sporgiophores arise directly fi'om vegetative nonseptate hyphae. On the basis o f the pfcceding criteria, 12 isolates were identified as Rhizopus and one as Absidia." Definitive speciation of the isolates was achieved througll the courtesy of Dr. John Ellis, Northern Regional Research Laboratory, U.S. Departinent of Agriculture, I'coria, Illinois, and Dr. Irene Weitzman, New York City Department of Health (Table 1). Serologically, four of the six sera assayed formed precipitin bands with the Rbizopus antigen only (Table 3). Two of these sera were derived from patients (numbers 29 and 30) with therapy responsive subcntaneous mucormycotic infection due to R. rhizopodoformis. The rexnaining two reactive sera were obtained from patients with leukemia (nunlbers .25 and 26) who developed fatal rhinocerebral disease. Tim two nonreactive sera were from patients (numbers 31 and 32) with puhnonary R. rhizopodoform/s infection, one of whom responded to therapy. Two of the six sera assayed for antifungal activity completely failed to inhibit the g r o w t h o f the test R. rhizopodoformis even when undiluted. These two sei'a, obtained from leukenfic patients 25 and 26, also demonstrated precipitin antibody to Rhizopus. T h e sera of the remaining four patients (nnmbers 29, 30, 31, and 32) with mucormycosis did demonstrate some fungal inhibitory activity, which occurred in sera
MUCORM YCOSIS- ,MARC!IEVSKYET AL. TABLE 3. MUCORMYCOSIS: C O R R E L A T I O N BETWEEN SERUM A N T I B O D Y LEVELS, SERUM F U N G I S T A T I C A C T I V I T Y , A N D O U T C O M E OF I N F E C T I O N * % S e r u m Required
Patient
Organ Involved
Presence of Precipitin
for Fungistatie Activity No inlfibition in undiluted serum No inhibition in undiluted serum 20-30% 20-30% 20-30% 20-30%'I" No inhibition in undiluted seru rll ~"
No.
Underlying Disease
25
Acute m)elogeuous leukemia
Orbit
+
26
Acute lymphocytic leukemia
Orbit
+
29 30 31 32
Surgery Renal transplant Acute myelogenous leukemia Acute myclogenous leukemia
Skin Skin Lung Lung
+ + 0 0 0
Normal
0
Outcome Died Died Survived Survived Survived Survived
5%
*As determined by the microdilution method of Kerbs et al. ~5 t S c r u m assayed six weeks later, just prior to patient's death. T h e mucormycotic abscess was still present in lung.
diluted to 20 to-30 per cent concentration. Patient 32 expired six weeks after the initial diagnosis. A second serum specimen collected just prior to death lacked fungistatic activity. Normal sera, in contrast, inhibited growtla o f the same R. rhizopodoformis spore suspenstun even after dilution to 5 per cent of the original concentration. In the environmental studies, exposed Petri dishes containing Sabouraud's agar demonstrated the presence of fimgal species such as Aspergillus, Penicillium, and Syncephalastrum, but were devoid of Mucoraceae. However, cultures of unopened Elastoplast adhesive bandage obtained from the surgical intensive care unit did grow out R. rhizopodoformis, io DISCUSSION
Mttcormycotic agents are found througllotat the world on fl-uit and bread, in air, and in soil where they exist as saprophytes. Rhinocerebral infection results from inimlation of airborne spores. In the nasal mucosa germination ensues and the hyphal elements penetrate by direct extension or througla vascular channels to the paranasal sinuses, orbit, brain, and occasionally even the eye. Pulmonary invasion results from either hematogenous spread fl-om a distal focus or airborne acquisition of spores.-", a l'uimonary infections still present the most difficult diagnostic challenge. In our series only two o f 12 .patients were diagnosed during life. In these two instances puhnonary fungal infection was strongly suspected clinically, and the diagnosis was achieved by observing the mucormycotic agent in specimens obtained by fiberoptic bronchoscopy and percutaneous needle lung biopsy. Both patients improved with treatment; one tmderwent lobectomy in addition to treatment with amphotericin B and the second received amphotericin B only. In contrast to prior reports, grossly distinct lesions of nmcorm)'cosis were rarely observed. '2. ta Indeed only one of the 10 pa-
tients examined at necropsy had grossly recognizable pulmonary infarction with vascular thrombosis. Similarly, nmcormycotic invasion of organs other than the lung was often grossly indistinct. Histologicall}', with one exception, typical a r e a s o f coagulative and llemorrhagic necrosis with ftmgal hyphae, moderate sttppurative inflammation, and vascular thrombi were observed. Foreign body type granulomas were present in three instances, once in the nose and twice in the hmg. A granulomatous response has been noted previously, ta In our experience mucormycotic foreign body type grantflomas differ fi'om epithelioid cell granulomas as seen in tuberculosis and other fimgal infections. T h e granulomas described in patients with subcutaneous Entomophthoraceae infection are also different, with epithelioid cells and a conspicuous eosinophilic component. 6 Nosocomial acquisition of a nmcormycotic infection has long been suspected but seldom documented. In this stud)' nosocomial contraction of mucormycosis was postulated in four patients. In the newborn (patient 18) with jugular vein involvement only, a catheter inserted into this vein may have served as the portal of entry of the fimgus. In three o f four patients (numbers 12, 29, and 30) with cutaneous and subcutaneous nmcormycosis caused by R. rhizopodoformis, infection followed a surgical procedure. In two of these patients (nnmbers 12 and 30) and possibly the third (number 29) Elastoplast adhesive bandage was applied over the site of the original lesions. R. rhizopodoformis was isolated from unopened Elastoplast bandages derived from the cardiac intensive care unit tltat housed patients 12 and 30.t~ Four of six patients with mucorinycosis respondcd to the inciting agent with an antibody response to Rhizopus. Altllough normal serum diluted to 5 per cent inhibited the gernfination of Rhizopus spores, the sera from the two leukemic patients (numbers 25 and 26) with orbital involvement lacked such flmgistatic activity even in the undiluted state and in the presence of anti-Rhizoptls antibody. The remaining four sera (patients 29, 30, 31, and 32) showed re-
463
H U M A N I ' A T I I O L O G Y - - V O L U M E 11, NUMBER 5 d t t c e d flmgistasis; at 20 to 30 p e r c e n t s e r u m c o n c e n t r a t i o n s inltibitory activity was absent.
T h e presence of serum antibody did not appear to influence germination of Rhizopus spores. Two of the sera that lacked flmgistatic activity did have anti-Rhizopus precipitins, but two additional sera lacking antibody demonstrated antifungal activity, although reduced. In this study a correlation was shown between tlte severity of the disease and the degree of serum fungistatic activity, irrespective of the presence of antibody. Patients 25 and 26 whose undihtted sera lacked inhibitory activity had a fiflminating fatal disease. Patients 29, 30, and 31 whose sera showed reduced initibitory activity had a more benign and therapeutically responsive disease. I'atient 32, wltose initial serum showed reduced fungistatic activity, had a six week clinical course with radiologic evidence of improvement of puhnonary mucormycosis. Noteworthy, however, was the disappearance of serum fungistatic activity just prior to death. Autopsy revealed an 8 cm. mucormycotic pulmonary abscess. Systemic invasion had not occurred. Continued clinical and serologic correlation is needed to bring into sharper focus t h e r o l e of serum fimgistasis as a prognostic guide. Whereas the presence of antibody may be diagnostic, the failure to demonstrate in vitro flmgistasis with the sera of potentially susceptible hosts may be of prognostic value.
ACKNOWLEDGMENTS Ludwig M. Deppisch, M.D., initiated this study and generottsly provided his resuhs for our use. T h e attthors wish to recognize Patrick Molt, M.D., a n d Allan N. Schwartz, M.D., because of their awareness of the need for clinical and laboratory correlation.
September 1980 Dr. Gigcr is a recipient of a grant from Analytab Products, Inc. (API), Plainview, New York. Olga Duff provided excellent secretarial assistance.
REFERENCES !. Pahauf, A.: Mycosis mncorina. Virchows Arch. I'ath. Anat., 102:543, 1885. 2. Baker, R. D. (Editor): Human Infections with Fungi, Actiuom)cetes and Algae. New York, Springer-Verlag, 1971, p. 832. 3. Rosen, P.: Opportunistic fimgal infections in patients with neoplastic disease, l'athol. Ann., 11:255, 1976. 9t. Singh,J., and Prasanna, N. M.: Phycomycosis in an apparently normal host. J. Otolar}'ngoI., 6:37, 1977. 5. Williams, A. O.: Pathology of phycomycosis due to Entomophtora and Basidiobolus species. Arch. l'athol., 87:13, 1969. 6. Clark, B. M., and Edington, E. G.: Subcutaneous phycomycosis and rhino-entomophthorom)cosis.I , Baker, R. D. (Editor): lluman Infections with Fungi, Actinom)cetes and Algae. New York, Springer-Verlag, 1971, p. 684. 7. Gale, G. R., and Welch, A. M.: Studies of opportunistic fungi: inhibition of Rhizopus oryzae by human serum. Am. J. Med. Sci., 241:604, 1961. 8. Owens, A. W., Schacklette, M. H., and Baker, R. D.: Antifungal factor in serum. I. Studies on Rhizopus rhizopodoformis. Sabouraudia, 4:179, 1965. 9. Keys,T. F., et al.: Nosocomial outbreak of Rhizopus infections associated with Elastoplast wound dressing. Minn. Mort. Morb. Wkl)'. Rep., 27:33, 1978. 10. Gartenberg, G., et al.: Hospital acquired nlucormycosis (Rhizopus rhisopodoformiO of skin and subcutaneous tissue: epidemiology, mycology and treatment. New Eng. J. Med., 299: 115, 1978. 11. Rosen, P.: Decreased frequency ofaspergillosis and mucormycosts (letter). New Eng. J. Med., 295:1319, 1976. 12. Medoff, G., and Kobayashi, G. S.: Pulmonary mucorm)cosis. New Eng. J. Mcd., 286:86, 1972. 13. Baker, R. D.: Pulmonary mucorinycosis. Amer. j. l'athol., 32:287, 1956. 14. Leong, A. S. Y.: Grantflomatous mcdiastinitis due to Rhizopus spccies. Amer. J. Clin. Pathol., 70:103, 1978. 15. Kerbs, S., Huttou, R. D., and Hollister, J. W.: Visual micromethod for assay of fnngal growth. Can. J. Microbiol., 24:574, 1978. Department of l'athology The Mount Sinai tlospital One Gustave Levy Place New York, New York 10029 (Dr. Marchevsky)
464